Jr. High Fall Blast Retreat!November 11-13, 2016 in NOME!Sign Up Today!$80 (Sign up and pay by October 28)$100 (Sign up and pay by November 4)​PLEASE NOTE!!(Once you have completed the registration form, you will be taken to the payment page to make your payment. Select 'Retreat Registration or Travel' from the drop-down menu, and enter your payment amount before checking out. )

2016 Student Permission and Assumption of Risk Form

Participant's Name *

First

Last

Birthdate (Month, Day, Year) *

Participant's Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Please list any medical issues, allergies, or medications *

Emergency Contact Name *

Emergency Contact Number *

​I, the undersigned, certify that I am the parent or legal guardian of:

Minor's Name *

I hereby give my consent to have my minor child participate in the following activity of Covenant Youth of Alaska: __CYAK Jr. High Fall Blast____ (hereafter “the activity”) on or about __November 11-13__, _2016_. In consideration of my consent to have my minor child participate in this event or program, I represent and agree that:

I am aware of the hazards and risks to my minor child’s person and property associated with my participation in a programs and events with Covenant Youth of Alaska, such hazards and risks including, but not limited to death or injury by accident, disease, weather conditions, inadequate medical services or supplies, criminal activity, and random acts of violence. I accept my minor child’s participation with full awareness of these risks, and, subject to any insurance coverages that may be available to me from any source, and only with respect to Covenant Youth of Alaska and its agents, officers, directors, and employees, Ivoluntarily assume all risk of death, injury, and illness associated with such risks, and any damage to my minor child’s personal property, and I releaseCovenant Youth of Alaska and its agents, officers, directors, and employers from any liability whatever arising as a result of death, injury, or illness that my minor child may suffer as a result of participation in activities with Covenant Youth of Alaska.

To the fullest extent permitted by law, I release Covenant Youth of Alaska, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless Covenant Youth of Alaska, its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child’s participation in the activity.

Further, being the parent or legal guardian of the minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child.

My minor child is not an employee of Covenant Youth of Alaska.

I attest and certify that my minor child has no medical conditions that would prevent him/her from participating in programs and events at Covenant Youth of Alaska.

I attest and certify that I have major medical insurance.

As a parent or legal guardian, I also understand that my major medical insurance will provide primary insurance coverage in the event of an injury requiring medical services for my minor child. I further understand that it is my responsibility to determine if my major medical insurance provides adequate insurance for my minor child’s needs. If I desire additional insurance, it is my responsibility to purchase that additional insurance.

I expressly waive any defense to the enforcement of any provision of this commitment arising from a claim of lack of consideration and warrant that this commitment constitutes a legal, valid, and binding obligation upon me enforceable against me in accordance with its terms.

I hearby give permission to use photos/video of ‘minor child’ for CYAK promotions and print material.

I expressly agree that this assumption of risk agreement is intended to be a broad and inclusive as permitted by law. I further state that I have carefully read the foregoing assumption of risk and understand its contents, and I voluntarily sign this release as my own free act, this is a legal document and I understand that I have the opportunity to consult with an attorney before signing it.

Parent/Guardian: Please click yes if you agree to the above statements * *